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Clinical Pathway Produces Sustained Improvement in Acute Gastroenteritis Care
Lori Rutman1,2, Eileen J Klein3,2, Julie C Brown3,2
1Department of Pediatrics, University of Washington, Seattle, Washington; and lori.rutman@seattlechildrens.org.
Insights
A clinical pathway for acute gastroenteritis (AGE) in children significantly reduced intravenous (IV) fluid use and emergency department (ED) length of stay (LOS). These improvements in pediatric care were sustained over a decade.
Area of Science:
- Pediatric Emergency Medicine
- Quality Improvement in Healthcare
- Gastroenterology
Background:
- Dehydrating illnesses affect millions of children globally each year, despite rotavirus vaccination.
- Oral rehydration therapy (ORT) is recommended for mild to moderate dehydration.
- Ondansetron is an effective adjunct for managing vomiting in pediatric patients.
Purpose of the Study:
- To evaluate the long-term impact of a clinical pathway for acute gastroenteritis (AGE) in a pediatric emergency department (ED).
- To assess changes in intravenous (IV) fluid administration and ED length of stay (LOS) post-pathway implementation.
Main Methods:
- Utilized International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes to identify patient cases.
- Employed statistical process control to analyze data from 2 years pre-implementation and 10 years post-implementation.
- Tracked key outcome measures including IV fluid use and ED LOS for discharged patients.
Main Results:
- Included 30,519 pediatric patients in the analysis.
- Observed a significant reduction in IV fluid administration, decreasing from 48% to 26% after pathway and ondansetron integration.
- Demonstrated a decrease in mean ED LOS for discharged patients from 247 minutes to 172 minutes, with sustained improvements.
Conclusions:
- A clinical pathway focusing on ORT and ondansetron effectively reduced IV fluid use and LOS in pediatric EDs for AGE.
- The observed improvements in care delivery were sustained over a 10-year period.
- Quality improvement initiatives for acute gastroenteritis can yield significant, long-term positive impacts on pediatric patient care.
Background And Objectives:
Despite widespread use of the rotavirus vaccine in the last decade, dehydrating illnesses impact almost 2 billion children worldwide annually. Evidence supports oral rehydration therapy as a first-line treatment of mild to moderate dehydration. Ondansetron has proven to be a safe and effective adjunct in children with vomiting. We implemented a clinical pathway in our pediatric emergency department (ED) in January 2005 to improve care for this common condition. Our objective in this study was to determine the long-term impact of the pathway for acute gastroenteritis (AGE) on the proportion of patients receiving intravenous (IV) fluids and ED length of stay (LOS) for discharged patients.
Methods:
Cases were identified by using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. We used statistical process control to analyze process and outcome measures for 2 years before and 10 years after pathway implementation.
Results:
We included 30 519 patients. We found special cause variation with a downward shift in patients receiving IV fluids after initiation of the pathway and later with addition of ondansetron to the pathway from 48% to 26%. Mean ED LOS for discharged patients with AGE decreased from 247 to 172 minutes. These improvements were sustained over time.
Conclusions:
Implementation of a clinical pathway emphasizing oral rehydration therapy and ondansetron for children with AGE led to decreased IV fluid use and LOS in a pediatric ED. Improvements were sustained over a 10-year period. Our results suggest that quality-improvement interventions for AGE can have long-term impacts on care delivery.
